Showing papers in "The Clinical Journal of Pain in 2013"

The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription.

Abstract: Objective Increasing rates of opioid use disorders (abuse and dependence) among patients prescribed opioids are a significant public health concern. We investigated the association between exposure to prescription opioids and incident opioid use disorders (OUDs) among individuals with a new episode of a chronic non-cancer pain (CNCP) condition.

A systematic review and meta-analysis of yoga for low back pain

Abstract: Objectives:To systematically review and meta-analyze the effectiveness of yoga for low back pain.Methods:MEDLINE, the Cochrane Library, EMBASE, CAMBASE, and PsycINFO, were screened through January 2012. Randomized controlled trials comparing yoga to control conditions in patients with low back pain

Central sensitization and altered central pain processing in chronic low back pain: fact or myth?

Abstract: Objective:The purpose of this narrative review is to analyze the available literature concerning central sensitization and altered central pain processing in patients with chronic low back pain (LBP).Methods:Literature was screened using several electronic search databases. Additional literature was

Pain Physiology Education Improves Health Status and Endogenous Pain Inhibition in Fibromyalgia: A Double-Blind Randomized Controlled Trial

Abstract: Objectives: There is evidence that education on pain physiology canhave positive effects on pain, disability, and catastrophization inpatients with chronic musculoskeletal pain disorders. A double-blind randomized controlled trial (RCT) was performed to examinewhether intensive pain physiology education is also effective infibromyalgia (FM) patients, and whether it is able to influence theimpaired endogenous pain inhibition of these patients.Methods: Thirty FM patients were randomly allocated to either theexperimental (receiving pain physiology education) or the controlgroup (receiving pacing self-management education). The primaryoutcome was the efficacy of the pain inhibitory mechanisms, whichwas evaluated by spatially accumulating thermal nociceptivestimuli. Secondary outcome measures included pressure painthreshold measurements and questionnaires assessing pain cogni-tions, behavior, and health status. Assessments were performed atbaseline, 2 weeks, and 3 months follow-up. Repeated measuresANOVAS were used to reveal possible therapy effects and effectsizes were calculated.Results: After the intervention the experimental group hadimproved knowledge of pain neurophysiology (P<0.001). Patientsfrom this group worried less about their pain in the short term(P=0.004). Long-term improvements in physical functioning(P=0.046), vitality (P=0.047), mental health (P<0.001), andgeneral health perceptions (P<0.001) were observed. In addition,the intervention group reported lower pain scores and showedimproved endogenous pain inhibition (P=0.041) compared withthe control group.Discussion: These results suggest that FM patients are able tounderstand and remember the complex material about painphysiology. Pain physiology education seems to be a usefulcomponent in the treatment of FM patients as it improves healthstatus and endogenous pain inhibition in the long term.Key Words: patient education, conditioned pain modulation, spa-tial summation, rehabilitation, central sensitization.

Lives on hold: A qualitative synthesis exploring the experience of chronic low-back pain

Abstract: Objectives:Chronic nonspecific low-back pain (CLBP) is a prevalent, costly condition that is remarkably resistant to intervention. Substantial evidence suggests that a mismatch exists between the biomedical beliefs held by clinicians and patients and the biopsychosocial nature of CLBP experience. Th

A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain.

Abstract: Objectives: Reconceptualization of pain and reduction of pain-related catastrophizing are primary objectives in chronic pain rehabilitation. Teaching people about the underlying biology of pain has been shown to facilitate these objectives. The objective of this study was to investigate whether written metaphor and story can be used to increase knowledge of the biology of pain and reduce pain-related catastrophizing. Methods: In this randomized single-blind partial cross-over controlled trial, 79 people with chronic pain received either a booklet of metaphors and stories conveying key pain biology concepts or a booklet containing advice on how to manage chronic pain according to established cognitive-behavioral principles. The primary outcome variables, pain biology knowledge and catastrophizing, were measured before randomization, at 3 weeks and at 3 months, at which time the control group was crossed over to receive the metaphors and stories booklet. Pain and disability were secondary outcome variables. Results: The Metaphors group showed larger changes in both variables (timegroup interactions: P < 0.01, effect size Cohen d = 0.7 for catastrophizing and 1.7 for pain biology knowledge). Gains were maintained for at least 3 months. Changes were replicated in the Advice group when crossed over. There was no change in pain or self-reported disability in either group. Discussion: We conclude that providing educational material through metaphor and story can assist patients to reconceptualize pain and reduce catastrophizing. Metaphor and story could be used as a precurser to other interventions that target functional capacity.

Chronic Pain After Surgery Time for Standardization? A Framework to Establish Core Risk Factor and Outcome Domains for Epidemiological Studies

Abstract: Introduction and Objectives: Many studies have reported putative factors for the development of chronic pain after surgery. However, advances in knowledge about the etiology and prognosis of chronic postsurgical pain (CPSP) could be gained by improving methodology within studies of surgical pain. The purpose of this study was to review predictive factors and to propose core risk factor and outcome domains for inclusion in future epidemiological studies investigating CPSP. Methods: Using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials as a framework we reviewed risk factor and outcome domains, methodological issues and standardized measurement tools based on findings from narrative and systematic reviews, primary clinical and epidemiological studies and published guidelines for chronic pain clinical trials. Results: Five “core” risk factor domains (demographic, pain, clinical, surgery-related, and psychological) and 4 outcome domains (pain, physical functioning, psychological functioning, and global ratings of outcome) were identified. Important methodological issues, related to the definition and timing of follow-up to assess transition from acute to chronic pain are discussed. We also propose the use of validated, standardized measurement tools to capture risk factor and outcome domains at multiple time points. Discussion: There is potential to advance the field of CPSP research by striving for consensus among pain experts; this would advance current evidence by improving our ability to compare findings from different studies and would facilitate the aggregation of surgical cohort datasets to allow international comparisons. We propose these findings as a starting point to build a comprehensive framework for epidemiological studies investigating chronic pain after surgery.

Oxytocin and pain: a systematic review and synthesis of findings.

Abstract: Objectives A review of the literature was conducted to assess the association between oxytocin (OT) and pain. Methods PsychInfo, PubMed, and Medline (EBSCO) research databases were searched for peer-reviewed articles written between 1950 and 2012. Of a total of 1166 articles returned, 50 (9 human, 33 animal, and 8 spinal cord samples) met full inclusion criteria and were included in the review. Results OT had a reliable effect as defined by increasing pain tolerance in 29 of 33 animal studies reviewed. This effect persisted across central and peripheral modes of administration and type of noxious stimulus used (eg, heat, electric). The results suggest that OT acts as an analgesic for acute pain in animals. Preliminary research with humans offers consistent evidence to suggest that OT decreases pain sensitivity, though the reliability and stability of such effects cannot yet be determined. Although the findings are encouraging, there is a need for methodologically rigorous work in humans where OT is administered centrally. Discussion Further research seems to be warranted as the existence of biologically and psychologically plausible mechanisms linking OT and pain have been well supported using animal models with limited but encouraging human research. Implications and recommendations are discussed. Findings from this research may inform therapeutic methods for the management of pain.

Correlates of prescription opioid initiation and long-term opioid use in veterans with persistent pain.

Abstract: Objectives:Little is known about how opioid prescriptions for chronic pain are initiated. We sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among veterans with persistent nonca

Activity pacing in chronic pain concepts, evidence, and future directions

Abstract: Background:Activity pacing (AP) is a concept that is central to many chronic pain theories and treatments, yet there remains confusion regarding its definition and effects.Objective:To review the current knowledge concerning AP and integrate this knowledge in a manner that allows for a clear definit

Improvement of pain, sleep, and quality of life in chronic pain patients with vitamin D supplementation.

Abstract: Objectives:To evaluate the effects of vitamin D supplementation in outpatient veterans with multiple areas of chronic pain.Methods:A case series was performed as an outpatient vitamin D supplementation quality improvement project. A total of 28 US veterans with multiple areas of chronic pain and low

The Interplay of Parent and Adolescent Catastrophizing and Its Impact on Adolescents’ Pain, Functioning, and Pain Behavior

Abstract: Objectives Catastrophizing is a coping style linked to poorer patient outcomes. Little attention has focused on the parent-adolescent dyad and catastrophizing as a shared coping style. The purpose of this study was to: (1) examine the effects of adolescent and parent pain catastrophizing on adolescent functioning and (2) explore concordance in catastrophizing in parent-adolescent dyads, with equal interest in outcomes of dyads with discordant coping styles.

Trends and regional variation in opioid overdose mortality among Veterans Health Administration patients, fiscal year 2001 to 2009.

Abstract: Objectives Opioid-related mortality has increased in the United States in the past decade. The purpose of this study was to examine trends and regional variation in opioid prescribing and overdose rates in a national health system, the Veterans Health Administration. Materials and methods Annual cohorts of Veterans Health Administration patients were identified on the basis of medical records, and overdose mortality was determined from National Death Index records. State-level prescribing and overdose rates were mapped to provide information on regional variability. Results There were significant increases between 2001 and 2009 in the rate of overdoses associated with nonsynthetic opioids (β=0.53, 95% confidence interval, 0.35, 0.70) and methadone (β=0.63, 95% confidence interval, 0.37, 0.90) but not synthetic/semisynthetic opioids. State-level overdose rates had a moderate correlation with the average proportion of patients in that state receiving opioids (r=0.29). Discussion The present study demonstrates that the increases in prescription opioid overdoses observed in the general population are also found in the patient population of a national health system and provides further evidence of the population-level association between trends in opioid prescribing and opioid overdose deaths. There is substantial regional variation in both opioid prescribing and opioid-related overdose rates, and these data can inform region-specific overdose prevention strategies and opioid policy.

Acupuncture for acute low back pain: a systematic review.

Abstract: Objectives:Although acupuncture has been frequently used for acute nonspecific low back pain (LBP), relevant systematic reviews indicate sparse and inconclusive evidence. This systematic review aimed at critically evaluating the evidence for/against acupuncture for acute LBP.Methods:We searched Medl

Effect of a long-lasting multidisciplinary program on disability and fear-avoidance behaviors in patients with chronic low back pain: results of a randomized controlled trial.

Abstract: Objective To evaluate the effect on disability, kinesiophobia, pain, and the quality of life of a long-lasting multidisciplinary program based on cognitive-behavioral therapy and targeted against fear-avoidance beliefs in patients with chronic low back pain. Study design parallel-group, randomized, superiority controlled study. Ninety patients were randomly assigned to a multidisciplinary program consisting of cognitive-behavior therapy and exercise training (experimental group, 45 patients) or exercise training alone (control group, 45 patients). Before treatment (T1), 5 weeks later (instructive phase, T2), and 12 (posttreatment analysis, T3) and 24 months after the end of the instructive phase (1-year follow-up, T4), all of the patients completed a booklet containing the Roland-Morris Disability Questionnaire Scale (primary outcome), the Tampa Scale for Kinesiophobia, a pain numerical rating scale, and the Short-Form Health Survey. A linear mixed model for repeated measures was used to analyze each outcome measure, and the reliable change index/clinically significant change method was used to assess the clinical significance of the changes. Results The linear mixed model analysis showed a remarkable group, time, and interaction effect for group * time in all of the primary and secondary outcomes (P always Conclusions The long-lasting multidisciplinary program was superior to the exercise program in reducing disability, fear-avoidance beliefs and pain, and enhancing the quality of life of patients with chronic low back pain. The effects were clinically tangible and lasted for at least 1 year after the intervention ended.

Mindfulness-based cognitive therapy for the treatment of headache pain: a pilot study.

Abstract: OBJECTIVE:: This pilot study reports the findings of a randomized controlled trial (RCT) investigating the feasibility, tolerability, acceptability, and initial estimates of efficacy of mindfulness-based cognitive therapy (MBCT) compared to a delayed treatment (DT) control for headache pain. It was hypothesized that MBCT would be a viable treatment approach and that compared to DT, would elicit significant improvement in primary headache pain-related outcomes and secondary cognitive-related outcomes. MATERIALS AND METHODS:: RCT methodology was employed and multivariate analysis of variance models were conducted on daily headache diary data and preassessment and postassessment data for the intent-to-treat sample (N=36), and on the completer sample (N=24). RESULTS:: Patient flow data and standardized measures found MBCT for headache pain to be feasible, tolerable, and acceptable to participants. Intent-to-treat analyses showed that compared to DT, MBCT patients reported significantly greater improvement in self-efficacy (P=0.02, d=0.82) and pain acceptance (P=0.02, d=0.82). Results of the completer analyses produced a similar pattern of findings; additionally, compared to DT, MBCT completers reported significantly improved pain interference (P 0.05, d's≤-0.24). DISCUSSION:: This study empirically examined MBCT for the treatment of headache pain. Results indicated that MBCT is a feasible, tolerable, acceptable, and potentially efficacious intervention for patients with headache pain. This study provides a research base for future RCTs comparing MBCT to attention control, and future comparative effectiveness studies of MBCT and cognitive-behavioral therapy.

The Impact of Low Back-related Leg Pain on Outcomes as Compared With Low Back Pain Alone: A Systematic Review of the Literature

Abstract: Objectives:Low back pain (LBP) with leg pain, especially with findings of nerve root involvement, is considered as a poor prognostic indicator although it seems to have a favorable natural resolution. It is unclear whether patients with LBP and leg pain are at the more severe end of the spectrum as

Botulinum toxin A in postherpetic neuralgia: a parallel, randomized, double-blind, single-dose, placebo-controlled trial.

Abstract: Objectives:Cumulative evidence support a beneficial effect of botulinum toxin A (BTX-A) in postherpetic neuralgia (PHN). We aimed to assess efficacy, safety, and tolerability of BTX-A in the management of PHN, performing a randomized, double-blind, single-dose, placebo-controlled trial.Methods:Thirt

Randomized-controlled trial comparing yoga and home-based exercise for chronic neck pain.

Abstract: Objectives:Chronic neck pain is a significant public health problem with only very few evidence-based treatment options. There is growing evidence for the effectiveness of yoga for relieving musculoskeletal disorders. The aim of this study was to evaluate the effect of Iyengar yoga compared with exe

Does Mobilization of the Upper Cervical Spine Affect Pain Sensitivity and Autonomic Nervous System Function in Patients With Cervico-craniofacial Pain?: A Randomized-controlled Trial

Abstract: Objectives:The aims were to investigate the effects of anterior-posterior upper cervical mobilization (APUCM) on pain modulation in craniofacial and cervical regions and its influence on the sympathetic nervous system.Methods:Thirty-two patients with cervico-craniofacial pain of myofascial origin we

The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review.

Abstract: Objectives:The aim of this systematic review is to assess the effectiveness of conservative treatments for patients with cervical radiculopathy, a term used to describe neck pain associated with pain radiating into the arm. Little is known about the effectiveness of conservative treatment for patien

Psychobiological correlates of improved mental health in patients with musculoskeletal pain after a mindfulness-based pain management program.

Abstract: Objectives:Mindfulness-based pain management programs (MBPMs) aim to improve mental and physical health in individuals with chronic pain. In this study, we investigated whether improvement in mental health might require (1) reduction in the sensory pain experience and brain correlates of that experi

Experimental Pain Responses Support Peripheral and Central Sensitization in Patients With Unilateral Shoulder Pain

Abstract: Objective: The aims of this study were to (1) examine the pattern of experimental pain responses in the affected and nonaffected extremities in patients with shoulder pain and (2) explore the intraindividual association between sensitization states derived from experimental pain testing. Methods: Experimental pain responses from 58 patients with shoulder pain (17 women, aged 18 to 52 y) were compared with those from 56 age-matched and sex-matched pain-free volunteers (16 women, aged 21 to 58 y). Experimental pain responses included pressure pain threshold (PPT), thermal pain threshold and tolerance, and suprathreshold heat pain response. Comparisons were made between the affected and nonaffected extremities of clinical participants and the average response of extremities in control participants. Peripheral and central sensitization indexes were computed for clinical participants using standardized scores and percentile cutoffs on the basis of the data from the control sample. Experimental pain responses in clinical participants observed beyond the 25th and 75th percentile of control sample responses were used for investigation of intraindividual association of sensitization states. Results: PPT at the acromion and masseter on the affected side of clinical participants were diminished compared with that on their nonaffected side (P<0.015). Bilateral sensitivity in clinical participants was noted for PPT at the acromion and suprathreshold heat pain response (P<0.015). Peripheral and central sensitization indexes demonstrated that individuals with shoulder pain present with variable patterns of peripheral and central sensitization. Conclusions: Collectively, experimental pain responses supported peripheral and central sensitization in response to pressure and thermal stimuli. No clear association was made between individuals exhibiting peripheral or central sensitization, thus suggesting heterogeneity in pain processing in this clinical population.

Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: a blinded, controlled study.

Abstract: Objectives:To identify the presence of myofascial trigger points (TrPs) and pressure pain threshold (PPT) levels in the shoulder muscles of both involved and uninvolved sides in patients with unilateral shoulder impingement syndrome (SIS).Methods:Twenty-seven patients with SIS and 20 matched control

The safety of liposome bupivacaine, a novel local analgesic formulation.

Abstract: Objective: Pooled safety data from 10 randomized, double-blind studies of liposome bupivacaine, a novel local analgesic formulation, were examined. Methods: Eight hundred twenty-three patients received liposome bupivacaine (dose, 66 to 532 mg) given locally at the surgical site in 5 different settings (hemorrhoidectomy, bunionectomy, breast augmentation, total knee arthroplasty, and hernia repair); 446 received bupivacaine HCl (dose, 75 to 200 mg) and 190 received placebo. Adverse events (AEs) were monitored for up to 36 days after administration. Results: Overall, 48% of patients were men and 21% were 65 years and older. Incidence of AEs was 62% for patients receiving liposome bupivacaine, versus 75% and 43% for patients receiving bupivacaine HCl and placebo, respectively. The most common AEs (incidence >10%) in the liposome bupivacaine arms were nausea, constipation, and vomiting. One death was reported in the liposome bupivacaine group and 1 in the bupivacaine HCl group; both deemed unrelated to study drug. Serious AEs were reported in 2.7% of patients receiving liposome bupivacaine, versus 5.4% and 1.1% of those receiving bupivacaine HCl and placebo, respectively. In both the liposome bupivacaine and bupivacaine HCl groups, 6% of patients experienced a cardiac AE; these were primarily tachycardia (4% vs. 5%, respectively) and bradycardia (2% vs. 1%, respectively). Overall incidence of treatment-related cardiac AEs was <1%; all were associated with liposome bupivacaine. All of these events were assessed by investigators as possibly related to study drug; all were mild or moderate in severity, and none required therapeutic intervention. Discussion: Liposome bupivacaine exhibited acceptable tolerability across 823 patient exposures.

Pedometer-driven Walking for Chronic Low Back Pain A Feasibility Randomized Controlled Trial

Abstract: Low back pain (LBP) has high lifetime prevalence with nonspecific LBP representing the majority of cases.(1) Relapses in pain (60%) and work absences (33%) are common,(1) making LBP one of the most costly conditions in the United Kingdom (total cost of £STG12,300 million, with the cost of informal care and production losses related to LBP contributing £STG10,668 million of this total figure).(2) Current research evidence supports the use of exercise- based treatment approaches for chronic low back pain (CLBP; pain persisting for at least 12 wk); in the United Kingdom, supervised group-based exercise programs are recommended, along with advice to stay physically active.(3) There is no specific guidance on how to self-direct participants to maintain or increase their physical activity (PA), although Savigny et al(3) refer to the National Institute for Clinical Health and Excellence (NICE) guidance on methods to increase PA.(4) One of the interventions identified in this review (NICE, 2006), was pedometer-driven walking, which can incorporate features considered important for increasing PA, that is, professional guidance, self-direction, and on-going professional support.(5) The evidence to support walking in people with CLBP is promising(6,7); however, it is not yet clear what approach works best. Hartvigsen et al(8) showed that supervised Nordic walking was as effective as unsupervised Nordic walking, and a trial by some of the current research team(9) is currently investigating the effects of a structured walking program according to ACSM guidelines (30 min, 5 times/ wk). Other approaches for promoting PA have advocated the use of step targets driven by a pedometer, for example, 10,000 steps, which can be accumulated throughout the day in bouts of at least 10 minutes, and where 3000 steps approximates to 30 minutes of walking.(10) It is not clear whether such an approach would be suitable for people with LBP, for example, in terms of how many steps they should or could accumulate, and what risks might be associated with this approach for this clinical population. No trial to date has investigated the use of a pedometer driven walking program in people with CLBP.(7) Therefore as a first step, before implementing a main RCT, we designed a preliminary study to test the feasibility of delivering a pedometer-driven walking program as an adjunct to a standard education/advice session in people with CLBP.(11) Our specific objectives were to: Assess recruitment and adherence rates in education/ advice (E) and education/advice plus pedometer-driven walking program (EWP) groups. Determine the incidence of adverse events (AEs), including musculoskeletal injuries, and level of overall satisfaction in both groups. Make between and within group comparisons and estimate effect sizes for changes in functional disability, PA levels, stage of change, fear avoidance, self-efficacy, health-related quality of life, psychosocial beliefs, general health, and participant satisfaction.

Anxiety but not Social Stressors Predict 12-Month Depression and Pain Severity

Abstract: Objectives To determine whether baseline anxiety and social stressors as well their early change (first 3 months) predict 12-month depression and pain severity. Methods We analyzed data from the Stepped Care for Affective Disorders and Musculoskeletal Pain study, a randomized clinical trial of a combined medication-behavioral intervention for primary care patients with chronic musculoskeletal pain and depression. Using multivariable linear regression modeling, we examined the independent association of baseline anxiety and social stressors with depression and pain severity at 12 months. In addition, we modeled whether changes in anxiety and social stressors predicted 12-month depression and pain severity. Results Overall, the sample (N=250) was 52.8% women with a mean age of 55.5 years, and a racial distribution of 60.4% white, 36.4% black, and 3.2% other. Depression and pain were moderately severe at baseline (mean SCL-20 depression=1.9 and Brief Pain Inventory pain severity=6.15) and similar across intervention and usual care arms. Baseline anxiety symptoms predicted both depression (t score=2.13, P=0.034) and pain severity (t score=2.75, P=0.007) at 12 months. Also, early change in anxiety predicted 12-month depression (t score=-2.47, P=0.014), but not pain. Neither baseline nor early change in social stressors predicted depression or pain severity. Conclusions Anxiety, but not social stressors predict 12-month depression and pain severity. The presence of comorbid anxiety should be considered in the assessment and treatment of patients with musculoskeletal pain and depression, particularly as a factor that may adversely affect treatment response.

Understanding the information and service needs of young adults with chronic pain: perspectives of young adults and their providers.

Abstract: Objective:To qualitatively explore the information and service needs of young adults (YAs) with chronic pain to inform the development of a web-based chronic pain self-management program.Methods:A convenience sample of YAs (n=17; aged 18 to 29 y) with chronic pain was recruited from 2 adult tertiary

Research to Encourage Exercise for Fibromyalgia (REEF): Use of Motivational Interviewing, Outcomes from a Randomized Controlled Trial

Abstract: Objectives Regular exercise is associated with important benefits in patients with fibromyalgia (FM). Unfortunately, long-term maintenance of exercise after a structured program is rare. The present study tested the efficacy of Motivational Interviewing (MI) to promote exercise and improve symptoms in patients with FM.

Opioid cessation and multidimensional outcomes after interdisciplinary chronic pain treatment.

Abstract: Objectives:Although the efficacy of interdisciplinary treatment for chronic noncancer pain has been well-established in the literature, there is limited research examining interdisciplinary programs that require opioid cessation. As the long-term use of opioid analgesics remains controversial, furth